Heritage Healthcare Of Hammond
Inspection history, citations, penalties and survey trends for this long-term care facility in Hammond, Louisiana.
- Location
- 1300 Derek Drive, Hammond, Louisiana 70403
- CMS Provider Number
- 195526
- Inspections on file
- 25
- Latest survey
- February 12, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Heritage Healthcare Of Hammond during CMS and state inspections, most recent first.
A resident with stroke, vascular dementia, cognitive deficits, and documented elopement risk had physician orders and a care plan requiring a wanderguard and census checks every two hours. On the survey day, review of the MAR showed that only one census check was completed during a 12-hour shift. The resident was later observed fully dressed in bed with shoes on and without a wanderguard, which was found in the bedside drawer; the resident reported having removed it about a month earlier and expressed a desire to go home. An LPN, an NP, and the DON all confirmed the resident had an active wanderguard order and that the device was not in place and the ordered census checks were not performed as required.
After the removal of two dedicated Shower Aides, multiple residents requiring staff assistance for bathing experienced significant delays, with some waiting hours or missing scheduled baths. Residents with complex medical needs, including those with skin conditions and mobility impairments, were observed waiting in hallways and reported unmet needs. CNAs and facility leadership confirmed that increased workloads and the staffing change led to extended wait times for baths and showers.
Nursing staff failed to document the date and their initials on wound dressings after treatments for two residents with pressure ulcers, and did not use dressings large enough to fully cover and protect a wound for one resident. Observations and staff interviews confirmed that dressings were missing required documentation and, in one case, did not fully cover the wound, leaving it exposed.
A resident receiving enteral nutrition via feeding tube did not have the feeding bag labeled with the required date, time, or nurse initials, contrary to physician orders and facility policy. Both an LPN and the DON confirmed the omission during interviews, and the administrator acknowledged that staff were expected to follow labeling procedures for enteral feedings.
Nursing staff were allowed to perform wound care treatments without verified training or competency evaluation, resulting in improper documentation and inadequate wound coverage for two residents. The facility relied on self-reported experience rather than direct observation or skills assessment, and wound dressings were not consistently dated, initialed, or applied according to policy.
A resident with COPD and multiple care needs was found with an Albuterol inhaler left unattended at bedside without a required assessment or physician's order for self-administration. Facility policy mandates assessment, interdisciplinary review, and proper documentation for self-administration, none of which were completed. Staff confirmed the medication should have been secured and that administration was not properly documented on the MAR.
The facility failed to accurately document care for two residents. One resident's wound care was not recorded on a specific date, while another resident's MAR inaccurately showed oxygen therapy administration, which the resident did not receive. Interviews with staff confirmed these documentation errors.
A facility failed to provide necessary respiratory care for a resident with Congestive Heart Failure and Chronic Respiratory Failure. The resident had a physician's order for oxygen therapy at 2 liters via nasal cannula, but was observed without oxygen in use. The resident confirmed not wearing oxygen since living at the facility. Interviews with an LPN and the DON revealed that the nursing staff did not follow the physician's order.
The facility failed to conduct complete weekly skin assessments for two residents at risk of pressure ulcers. An LPN only assessed visible skin, neglecting areas under clothing, despite orders for comprehensive audits. The DON acknowledged the oversight, noting that education on full assessments was provided but not fully understood.
The facility did not ensure that all complaint surveys since the last annual survey were available for resident review. An observation revealed that the survey results folder only contained the annual recertification survey, missing the complaint survey from November 2024. The administrator confirmed the absence of these results, potentially affecting 88 residents.
A facility failed to accurately code a resident's MDS for an indwelling catheter. The resident was readmitted with a catheter, as noted in the Clinical Admission Screener, but the MDS did not reflect this. Observations confirmed the catheter's presence, and the staff responsible for MDS assessments acknowledged the error after the MDS was submitted to CMS.
A resident with a history of pulmonary embolism did not receive Eliquis as ordered due to an LPN discontinuing the medication without a physician's order. The resident was found unresponsive and later pronounced dead, with the coroner's report indicating acute myocardial infarction vs pulmonary embolism as the cause of death. The facility's failure to follow proper medication administration and documentation processes led to this significant medication error.
A resident who was cognitively intact and dependent on staff for bathing complained about not receiving a bath for five days. Despite an immediate response, the issue persisted, with the resident experiencing significant gaps between baths over two months. The ADON confirmed the complaint but admitted no measures were taken to prevent recurrence, violating the facility's grievance policy.
The facility failed to maintain an infection prevention and control program, as two LPNs did not practice proper hand hygiene during medication administration for three residents, and one LPN did not disinfect a blood glucose meter between resident use. Both LPNs and the DON confirmed these lapses in protocol.
The facility failed to ensure a resident's assessment accurately reflected their status. A resident with a diagnosis of Localized Edema, who was receiving Lasix daily, was not coded for this active diagnosis in the Quarterly MDS. This discrepancy was confirmed by staff during interviews.
A facility failed to develop a comprehensive care plan for a diabetic resident who frequently refused blood glucose monitoring. Despite multiple refusals documented over several months, no care plan was created to address this issue, as confirmed by the MDS nurse and DON.
A resident with Morbid Obesity and Chronic Diastolic Heart Failure did not receive necessary personal hygiene services as scheduled. Despite requiring substantial assistance, the resident received baths only four times over two months, leading to unkempt appearance and poor hygiene. Staff confirmed difficulties in providing showers due to lack of assistance and no accommodations were made.
The facility failed to ensure that oxygen tubing was labeled with the date for two residents who required continuous oxygen therapy. Observations and staff interviews confirmed that the tubing was not dated as per physician orders and facility protocol.
The facility failed to ensure that PRN psychotropic medications for two residents receiving Hospice care had stop dates or duration limits. Both residents had active orders for Lorazepam without a documented stop date, which was confirmed by the Hospice RN, Hospice Physician, and DON.
The facility failed to post daily nurse staffing data, including the resident census, in two observed areas. Observations and interviews confirmed the omission, with the ADON admitting she was unaware of the requirement.
Failure to Ensure Wanderguard Use and Required Census Checks for Elopement-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and follow physician orders for an elopement-risk resident. The resident was admitted with stroke, vascular dementia with behavioral disturbance, cognitive communication deficit, and Wernicke’s encephalopathy, and had a BIMS score of 8 indicating moderate cognitive impairment. The resident’s elopement risk evaluation documented that he was an elopement risk due to expressing a desire to go home, packing belongings, or staying near exit doors, and he had an active order to continue using a wanderguard. The care plan identified him as an elopement risk/wanderer who made statements about leaving, required a wanderguard, and needed cueing, reorientation, and supervision due to impaired cognitive status. Physician orders and the MAR specified wanderguard census checks every two hours. On the day of the survey, review of the MAR showed that the ordered every-two-hour census checks were not completed for the 7:00 a.m. to 7:00 p.m. shift, with only one census check documented at 10:48 a.m. When observed at 2:07 p.m., the resident was fully dressed in bed, wearing shoes, without a wanderguard in place, and he stated he had removed the wanderguard about a month earlier and expressed a need to go home to mow the grass and grate his driveway. The wanderguard was found in the top drawer of his bedside table. The NP and DON both confirmed the resident had an order for a wanderguard due to elopement risk and that it was not in place as it should have been. The LPN assigned to the resident confirmed she was unaware the wanderguard was not on the resident, acknowledged she had only performed one census check during her shift, and confirmed she did not complete the ordered every-two-hour census checks.
Insufficient Staffing Leads to Delays in Resident Bathing
Penalty
Summary
The facility failed to provide sufficient numbers of direct care staff to ensure timely assistance with baths and showers for all residents, as evidenced by observations, interviews, and record reviews. The facility had a policy requiring showers to be given as scheduled and/or as needed, and residents were not to be left alone in the shower room. However, after the removal of two dedicated Shower Aides from daily assignments, residents experienced significant delays in receiving their scheduled baths and showers, with some waiting in excess of two to three hours. Multiple residents were observed waiting in wheelchairs outside the bath/shower room for extended periods, and several reported missing activities or having to clean themselves due to the lack of available staff. Residents affected included individuals with complex medical needs, such as one with chronic skin conditions requiring daily bathing to prevent infection and control odor, and others with severe morbid obesity, congestive heart failure, and mobility impairments. These residents were assessed as requiring varying levels of staff assistance for activities of daily living, including bathing. Despite their care plans indicating the need for staff support, residents consistently reported long wait times and unmet needs following the staffing change. Resident council meeting minutes and direct interviews confirmed that the new process was not working, and residents' preferences and schedules for bathing were not being honored. Staff interviews corroborated the residents' accounts, with CNAs reporting increased workloads after being reassigned from dedicated shower duties to broader floor responsibilities. CNAs described being responsible for large numbers of residents, many of whom required two-person assistance, frequent turning, repositioning, and incontinence care, making it difficult or impossible to provide timely baths and showers. Facility leadership acknowledged the recent system change and the resulting delays, stating that the facility was still working out issues with the new staffing model, but confirmed that residents' needs were not being met in a timely manner.
Failure to Document and Properly Apply Pressure Ulcer Dressings
Penalty
Summary
The facility failed to provide pressure ulcer care in accordance with professional standards and its own wound care policy for two of four residents reviewed. Specifically, nursing staff did not document the date and their initials on wound dressings after performing treatments, as required by facility policy. Observations revealed that dressings on multiple wound sites, including the sacrum, bilateral heels, and right ischium, lacked this essential documentation. Interviews with the wound treatment nurse and a CNA confirmed that the dressings were missing the date and initials, and the nurse was unaware of who performed the treatments on certain days. The absence of this information was acknowledged as important for tracking when treatments were performed and for monitoring wound drainage over time. Additionally, the facility failed to ensure that wound dressings were large enough to fully cover and protect the wounds for one resident. An observation showed that a sacral wound dressing did not extend past the edges of the wound, leaving a significant portion of the wound exposed to air and potential contaminants. Both the wound treatment nurse and nurse practitioner confirmed that dressings should fully cover wounds as ordered, and that the observed practice did not meet this standard. The Director of Nursing and facility administrator also confirmed that dressings should completely cover wounds and include the date and initials of the person performing the treatment.
Failure to Label Enteral Feeding Bag per Policy and Physician Orders
Penalty
Summary
The facility failed to ensure that a resident receiving enteral nutrition via a feeding tube was provided with appropriate treatment and services to prevent complications. Specifically, the enteral feeding bag in use for a resident with a gastrostomy was not labeled with the required date, time, or nurse initials, as observed during a survey. This omission was in direct violation of both physician orders and the facility's own policy, which require that the formula container, syringe, and administration set be labeled with the resident's name, date, time, and nurse's initials at the start of infusion. Record review showed that the resident was receiving continuous enteral nutrition due to dysphagia, with orders specifying the use of a closed system container and the need to change and label the feeding administration set with each new bottle. During interviews, both the LPN and the Director of Nursing confirmed that the labeling had not been completed as required. The facility administrator also acknowledged that staff were expected to follow physician orders and facility policy regarding enteral feedings, but this was not done in this instance.
Failure to Ensure Nursing Staff Competency in Wound Care Treatments
Penalty
Summary
The facility failed to implement a measurable evaluation system to ensure that nursing staff were properly trained and competent to perform wound treatments as ordered before being allowed to do so independently. Observations revealed that wound dressings for two residents did not have the required date and initials of the nurse who performed the treatment, as specified in the facility's wound care policy. Additionally, one resident's wound dressing was not large enough to fully cover and protect the wound, leaving a portion exposed to air and potential contaminants. Interviews with staff indicated that the facility assigned various nurses, including those not regularly performing wound care, to conduct wound treatments on weekends. One LPN, who was assigned to perform wound treatments, confirmed she had not received recent training or competency evaluation for wound care and was unaware of the requirement to date and initial dressings. The staff development nurse responsible for training and competency evaluations admitted she did not provide actual training or observe wound care skills, instead relying on self-reported experience from the nurses. She also acknowledged she was not competent in wound care herself and could not evaluate others in this skill. Further interviews with the DON and administrator confirmed that wound care is considered a specialized skill requiring specific training and competency evaluation, which was not being conducted. The staff development nurse's initials on competency forms only indicated that she asked nurses if they had performed the skill before, not that she had observed or evaluated their competency. This lack of a structured training and competency evaluation system resulted in nurses performing wound care without verified skills, leading to improper documentation and inadequate wound coverage for residents.
Failure to Ensure Safe Medication Administration and Storage
Penalty
Summary
The facility failed to ensure the safe disposition and administration of medications for a resident, as evidenced by the presence of an Albuterol Sulfate Inhaler left unattended at the bedside of a resident with chronic obstructive pulmonary disease (COPD), cognitive communication deficit, lack of coordination, weakness, and a disorder of the brain. The resident was assessed as cognitively intact but required varying levels of assistance with daily activities, including substantial or maximal assistance with toileting, bathing, and dressing. Despite these needs, there was no documented assessment for the resident's ability to self-administer medications, nor was there a physician's order permitting self-administration or allowing the inhaler to be kept at bedside. Review of the facility's policy indicated that residents must be assessed for self-administration of medication upon admission, quarterly, annually, with significant changes, or as needed. The policy also required an interdisciplinary team review, a physician's order, and care plan updates if self-administration was approved. In this case, the resident's clinical record, care plan, and medication administration record (MAR) showed no evidence of such an assessment, order, or care plan update. The MAR also lacked documentation of the inhaler being administered during the review period, despite the resident's need for frequent use of the inhaler for shortness of breath. Interviews with facility staff, including an LPN, the Director of Nursing, and the Administrator, confirmed that the resident had not been assessed for self-administration, did not have a physician's order for self-administration or for the inhaler to be kept at bedside, and that the medication should have been secured in the medication cart when not in use. Staff also confirmed that, even if self-administration were permitted, the date and time of administration should be documented on the MAR, which was not done in this case.
Documentation Errors in Wound Care and Oxygen Use
Penalty
Summary
The facility failed to maintain accurate documentation for two residents, leading to deficiencies in care. For one resident, the Treatment Administration Record (TAR) for January 2025 was found to be incomplete, as it lacked documentation of daily wound care for a surgical incision on January 1, 2025. Interviews with the LPN and the Director of Nursing confirmed that the documentation was missing and should have been completed, indicating a lapse in maintaining accurate medical records. For another resident, the Medication Administration Record (MAR) for February 2025 inaccurately documented the administration of oxygen therapy. Despite the MAR indicating that the resident received oxygen on multiple dates, an observation and interview with the resident revealed that he did not use oxygen at all during his stay. The LPN responsible for the documentation confirmed the error, acknowledging that the resident did not receive the treatment as recorded. This discrepancy highlights a failure in ensuring accurate documentation of treatments provided to residents.
Failure to Administer Ordered Oxygen Therapy
Penalty
Summary
The facility failed to provide necessary respiratory care for a resident, as observed during a survey. Resident #3, who was admitted with diagnoses including Congestive Heart Failure and Chronic Respiratory Failure, had a physician's order for oxygen therapy at 2 liters via nasal cannula. However, during an observation, Resident #3 was found resting in bed without oxygen in use. The resident confirmed that he had not been wearing oxygen since living at the facility. Interviews with the LPN and the Director of Nursing revealed that the nursing staff did not follow the physician's order to administer the prescribed oxygen therapy to Resident #3.
Inadequate Skin Assessments for Residents at Risk of Pressure Ulcers
Penalty
Summary
The facility failed to ensure accurate weekly skin assessments for two residents, both of whom were at risk for pressure ulcers. Resident #2 was admitted with a physician order for a weekly body audit starting on 12/31/2024, and Resident #3 had a similar order starting on 01/24/2025. However, the Licensed Practical Nurse (LPN) responsible for these assessments, S3LPN, admitted to only assessing the skin visible to her eyes and not under any clothing, relying on CNAs or shower aides to report any skin breakdown in areas covered by clothing. The Director of Nursing (DON), S2DON, confirmed that the responsibility for weekly skin audits lay with the LPN caring for the resident. Although education was provided upon hire on how to conduct complete skin audits, including checking less visible areas such as cracks, crevices, and behind the ears, it was not clear to some nurses that they should also assess the larger areas of skin under clothing. This oversight in the skin assessment process led to the deficiency identified by the surveyors.
Facility Failed to Provide Access to Complaint Survey Results
Penalty
Summary
The facility failed to ensure that all complaint surveys since the last annual survey were available for resident review. During an observation, it was noted that the facility's folder containing survey results, located on the bulletin board, only included the annual recertification survey dated June 7, 2024. There was no documented evidence of the complaint survey results from November 13, 2024, being available for review. This was confirmed during an interview with the facility's administrator, who acknowledged that the complaint survey results were missing from the folder. This deficiency had the potential to affect the 88 residents currently residing in the facility.
Inaccurate MDS Coding for Indwelling Catheter
Penalty
Summary
The facility failed to ensure that a resident's Minimum Data Set (MDS) accurately reflected the resident's status, specifically regarding the presence of an indwelling catheter. Resident #2 was admitted to the facility and later readmitted from a local hospital with an indwelling catheter, as documented in the Clinical Admission Screener. However, the Significant Change MDS with an Assessment Reference Date of 11/01/2024 did not code for the indwelling catheter, despite observations on 11/12/2024 and 11/13/2024 confirming the presence of the catheter. During an interview, the staff member responsible for completing MDS assessments acknowledged the error and confirmed that the MDS had been submitted to CMS without accurate coding.
Failure to Administer Eliquis as Ordered
Penalty
Summary
The facility failed to ensure that a resident received Eliquis as ordered by the physician, resulting in a significant medication error. The resident, who had a history of pulmonary embolism and acute embolism and thrombus of the lower extremity, was admitted with orders to take Eliquis 5 mg twice daily. However, the medication was discontinued by an LPN without a physician's order, and the resident did not receive Eliquis from the date of discontinuation until their death. The resident was found unresponsive, pulseless, and not breathing, and the coroner's report indicated the cause of death as acute myocardial infarction vs pulmonary embolism, hypertension, and changes of aging. The LPN who discontinued the Eliquis order did so without proper documentation or a physician's directive, believing the resident had an upcoming procedure. The Director of Nursing confirmed that there was no documentation or order to discontinue the medication, and the medication was removed from the Medication Administration Record (MAR) without proper authorization. The facility's process for verifying medication orders was not followed, leading to the resident not receiving the necessary anticoagulant medication. Interviews with the nursing staff revealed that the facility had recently implemented a new computer system, which may have contributed to the error. The Data Entry nurse and other staff were responsible for ensuring the accuracy of medication orders, but the error was not identified until after the resident's death. The facility's failure to administer Eliquis as ordered and the lack of proper documentation and verification processes directly contributed to the resident's death.
Failure to Resolve Resident Grievances Regarding Bathing
Penalty
Summary
The facility failed to initiate and resolve grievances voiced by a resident who was cognitively intact and dependent on staff for bathing. The resident had complained about not receiving a bath for five days, and although a bath was given immediately after the complaint, the issue persisted. The resident's care records showed infrequent bathing, with significant gaps between baths over two months. Despite the resident's complaint in April, the facility did not implement measures to prevent recurrence, leading to the resident appearing unkempt and reporting another instance of not being bathed for seven days in June. During an interview, the Assistant Director of Nursing (ADON) confirmed that the resident had complained about not being bathed and that she had personally bathed the resident. However, the ADON admitted that no measures were put in place to prevent the issue from happening again. This lack of follow-up and resolution is a clear violation of the facility's grievance policy, which mandates a resolution within five business days of the grievance being filed.
Infection Control Deficiencies
Penalty
Summary
The facility failed to maintain an infection prevention and control program, as evidenced by improper hand hygiene practices and inadequate disinfection of medical equipment. Specifically, two LPNs did not sanitize their hands before and after administering medications to three residents. One LPN was observed administering medication to a resident without performing hand hygiene before or after the process. Another LPN also failed to sanitize her hands before preparing and administering medications to two residents consecutively. Both LPNs acknowledged their failure to follow the facility's hand hygiene policy during interviews. Additionally, the facility did not ensure proper disinfection of blood glucose meters between resident use. An LPN was observed performing a blood glucose check on a resident and then placing the glucometer back in the medication cart without sanitizing it. The LPN confirmed that she did not clean the glucometer after use, which is against the facility's policy. The Director of Nursing also confirmed that the glucometer should be cleaned before and after each resident use and that hand hygiene should be performed before and after administering medications to each resident.
Failure to Accurately Reflect Resident's Status in MDS
Penalty
Summary
The facility failed to ensure a resident's assessment accurately reflected the resident's status. Resident #10, who was admitted with a diagnosis of Localized Edema, had been receiving Lasix 40 mg daily as prescribed. However, the Quarterly MDS with an ARD of 05/15/2024 did not code Localized Edema as an active diagnosis in Section I. This discrepancy was confirmed by S10MDS and S2DON during interviews, who acknowledged that the MDS should have included the diagnosis since the resident was actively receiving medication for it.
Failure to Develop Care Plan for Diabetic Resident Refusing Blood Glucose Monitoring
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident with diabetes who frequently refused blood glucose monitoring. The resident, who had diagnoses including Type 2 Diabetes Mellitus with unspecified complications and diabetic neuropathy, had multiple instances where Accu Checks were not administered due to refusal. Despite these frequent refusals, no care plan was developed to address this issue, as confirmed by the review of the resident's clinical records and MAR for March, April, and May 2024. The facility's policy requires that care plans be revised to reflect changes in the resident's behavior and care needs, but this was not done for the resident in question. Interviews with the MDS nurse and the DON revealed that the resident's frequent refusals of Accu Checks were discussed in daily morning meetings. However, the MDS nurse, who was responsible for updating care plans, did not recall these discussions and was not aware of the frequent refusals. Consequently, no care plan was developed to address the resident's refusals, which was a clear oversight in adhering to the facility's policy. Both the MDS nurse and the DON confirmed that a care plan should have been developed for the resident's frequent refusals of Accu Checks.
Failure to Provide Necessary Personal Hygiene Services
Penalty
Summary
The facility failed to ensure that Resident #17 received the necessary services to maintain personal hygiene. The resident, who was admitted with diagnoses including Morbid Obesity and Chronic Diastolic Heart Failure, required substantial assistance with bathing. Despite the facility's policy that baths and showers should be given as scheduled and as needed, records showed that Resident #17 received baths only four times over a two-month period. Observations and interviews revealed that the resident was unkempt, with oily hair, dandruff, and flaky skin, and had not received a bath or hair wash for seven days. The resident confirmed that her scheduled bath days were Mondays, Wednesdays, and Fridays, and expressed a preference for showers or whirlpool baths over bed baths. However, she often did not receive these due to staffing issues and difficulty getting her into a shower chair without assistance. Interviews with staff members, including the Assistant Director of Nursing (ADON) and a Certified Nursing Assistant (CNA), confirmed that Resident #17 had difficulty getting into the shower chair and required assistance, which was often unavailable. The CNA admitted to giving the resident bed baths instead of showers due to these challenges but also acknowledged that there were times when the resident did not receive any form of bath before the end of her shift. The ADON confirmed that no accommodations were made to ensure the resident received her scheduled baths, leading to the observed deficiency in personal hygiene care.
Failure to Label Oxygen Tubing
Penalty
Summary
The facility failed to provide necessary care and services for the provision of respiratory care in accordance with professional standards of practice. Specifically, the facility did not ensure that oxygen tubing was labeled with the date for two residents who required continuous oxygen therapy. Resident #5, who was admitted with diagnoses including Chronic Respiratory Failure, Chronic Obstructive Pulmonary Disease, and Obstructive Sleep Apnea, had physician orders to change and label oxygen tubing weekly. However, multiple observations revealed that the oxygen tubing in use was not dated. Interviews with the resident and staff confirmed that the tubing should have been dated but was not. Similarly, Resident #17, who was admitted with diagnoses including Chronic Obstructive Pulmonary Disease and Chronic Respiratory Failure with Hypoxia, also had physician orders to change and label oxygen tubing weekly. Observations of Resident #17 revealed that the oxygen tubing in use was not dated. Staff interviews confirmed that the tubing should have been dated according to the facility's protocol. The Assistant Director of Nursing also confirmed that the protocol for oxygen tubing changes was not followed as required.
Failure to Ensure PRN Psychotropic Medications Have Stop Dates
Penalty
Summary
The facility failed to ensure residents' drug regimens were free from unnecessary psychotropic medications for two residents. Resident #4, who was admitted with diagnoses including Dementia, Anxiety Disorder, Major Depressive Disorder, and Alzheimer's Disease, had active physician orders for Ativan and Lorazepam without a documented stop date. Similarly, Resident #7, admitted with diagnoses such as Senile Degeneration of Brain, Unspecified Dementia, Bipolar Disorders, and Major Depressive Disorder, had a PRN order for Lorazepam without a stop date. Both residents were receiving Hospice services, and the orders for psychotropic medications did not comply with the requirement to have a stop date or duration limit of 14 days for PRN use. Interviews with the Hospice Registered Nurse, Hospice Physician, and the Director of Nursing (S2DON) confirmed that the PRN orders for Lorazepam for residents receiving Hospice care did not include a stop date or duration. The Hospice Physician was unaware of the requirement for a stop date, and the Director of Nursing confirmed that the facility did not require stop dates for PRN Lorazepam orders for Hospice residents. This oversight led to the deficiency in ensuring that residents' drug regimens were free from unnecessary psychotropic medications.
Failure to Post Daily Nurse Staffing Data
Penalty
Summary
The facility failed to post nurse staffing data on a daily basis, including the total resident census number, in two observed areas. On 06/04/2024, observations at 9:46 a.m. and 9:50 a.m. revealed that the Daily Nursing Assignment sheets posted at Nursing Station A and the bulletin board at the end of Hall B did not include the resident census. Interviews with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) confirmed that the resident census number was missing from the posted sheets. The ADON, responsible for posting the sheets, admitted she was unaware that the resident census needed to be included.
Latest citations in Louisiana
A resident with Parkinson’s disease, essential tremor, dementia, and legal blindness, who was care planned as being at risk for burns from hot liquids and to receive hot beverages in lidded cups at temperatures not exceeding 130°F, sustained 2nd and 3rd degree burns to the left thigh after spilling coffee during a group activity. The facility’s policy required hot beverages to be cooled to 120–130°F and mandated temperature monitoring, but the coffee served at the time of the incident was reported by dietary staff to be 140°F, and the coffee temperature log did not include documentation for the 10:00 a.m. service when the spill occurred. This failure to adhere to the hot beverage policy and to consistently monitor and document beverage temperatures resulted in actual harm to the resident.
A resident with severe cognitive impairment, multiple chronic conditions, and hospice services required extensive assistance for transfers. During a transfer from wheelchair to bed performed by a CNA, the resident’s left lower leg rubbed against an enabler bar that had a missing end cap, creating a sharp edge. An LPN observed a large laceration on the leg and identified the defective enabler bar as the source of injury. The resident was sent to the ED, where a deep, 25.5 cm stellate laceration required extensive cleaning, internal and external sutures, a tetanus shot, and subsequent daily wound care and antibiotics due to delayed healing. The incident occurred despite facility policies and the Maintenance Supervisor’s responsibilities requiring regular inspection of bed rails and enabler bars for hazards.
The facility did not maintain the required 8 consecutive hours of daily RN coverage on multiple days, as time card records showed that the only scheduled RN worked less than 8 hours on several occasions. The administrator confirmed that this RN was the sole RN scheduled during the period reviewed and acknowledged that full daily RN coverage was not provided on the identified days.
The facility failed to maintain adequate supplies of clean bath towels and bed linens despite its own assessment identifying the need to keep sufficient PAR levels for these items. A resident with a history of traumatic brain injury and another with type 2 DM and asthma, both cognitively intact, reported that towels and linens were often unavailable, with one resident’s family providing personal linens due to frequent shortages. The grievance log documented a complaint about missing personal towels and sheets, and staff, including laundry personnel, a CNA, and the ADON, confirmed that clean towels and bed linens were frequently unavailable during multiple weeks, affecting all residents in the facility.
A resident with severe cognitive impairment, dementia, and multiple comorbidities, assessed as high risk for elopement due to prior exit-seeking and wandering, was found alone outside near the front entrance in a flower bed by an oncoming LPN. The LPN assisted the resident and notified staff inside, and the responsible party later reported the same event. Despite a written wandering and elopement policy requiring notification of regulatory agencies after such incidents, the Administrator acknowledged that this elopement was not reported to the State Survey Agency as required by state law.
A resident with multiple conditions, including type 2 DM, dementia with behavioral symptoms, gait abnormalities, and an anxiety disorder, was documented in progress notes as having eloped and been found outside in a flower bed, and later was found to have a diabetic ulcer on the right heel. Review of the comprehensive care plan showed it was not revised to address either the elopement or the new diabetic ulcer, and the MDS coordinator acknowledged that the care plan should have been updated to reflect these changes in condition.
A resident with type 2 DM, dementia, mobility impairments, and other comorbidities was admitted with a documented deep tissue injury on the right heel, but no corresponding MD wound care orders or treatments were recorded for approximately one month despite a care plan directive to assess for skin breakdown and treat as ordered. A NP note referenced treatment with gentian violet and foam, yet this was not supported by physician orders or the TAR. Later, a wound care nurse identified a diabetic ulcer on the same heel and initiated gentian violet and foam dressings after an order was finally obtained, with treatments documented on only a few dates. The resident was later seen in the ED for cellulitis related to the diabetic heel ulcer and discharged with antibiotics, and both the wound care nurse and NP confirmed gaps in assessment, ordering, and follow-up of the heel wound.
Staff failed to follow infection control protocols during incontinence care for two residents, including not performing required hand hygiene between glove changes and after contact with stool, and placing soiled items on clean linens. CNAs provided perineal care, handled residents’ clean clothing, body surfaces, wheelchairs, and room surfaces, and managed soiled briefs and pads without appropriate glove changes or hand sanitizing, contrary to facility policy. Both CNAs later acknowledged they should have performed hand hygiene and changed gloves correctly, and the DON confirmed that staff are expected to follow these infection prevention practices.
Two residents were not treated in a manner that promoted dignity and quality of life. One resident with left-sided weakness and a flaccid arm following a stroke requested a bedpan, but a CNA told her she was wearing a diaper and could use it instead, despite therapy having recommended bedpan use and the resident not wanting to use a diaper. Another resident with vascular dementia, a history of C. diff enterocolitis, heart failure, and depression, and a moderately impaired BIMS score continued to receive meals on disposable dishware in the dining room even though contact isolation precautions had been discontinued, and nursing leadership confirmed this should not have occurred.
A resident with paraplegia, severe cognitive impairment (BIMS 6), and dependence for mobility and hygiene was repeatedly observed in bed and in a Geri chair without access to a call light, despite facility policy requiring call lights to be within easy reach when residents are in bed or confined to a chair. On multiple occasions throughout the day, the call light was found on the floor or hanging on the side of the bed, out of the resident’s reach. The resident reported being unable to reach the call light, and both a CNA and the DON acknowledged that the call light was not within reach and should have been accessible.
Resident Burn from Overheated Coffee and Failure to Follow Hot Beverage Policy
Penalty
Summary
The deficiency involves the facility’s failure to ensure the environment was free from accident hazards and that residents received adequate supervision to prevent accidents, specifically related to serving hot beverages. The facility had a written policy titled “Serving Hot Beverages and Soup,” revised in 07/2007, which required the Food Service Department to monitor the temperature of all hot liquids to prevent burns if they contacted skin. The policy specified that coffee should be chilled to 120–130°F before being served and that the Food Service Department was responsible for ensuring all hot beverages, including those for activities, left the kitchen at the proper temperature. However, the coffee temperature log for March only included entries for 6:00 a.m. and 2:00 p.m., with no slot or documentation for 10:00 a.m. coffee temperatures, despite coffee being served at that time. Resident #1 was admitted with diagnoses including Parkinson’s disease, unspecified dementia, essential tremor, and legal blindness. A quarterly MDS with an ARD of 12/31/2025 showed a BIMS score of 13, indicating the resident was cognitively intact, and Section GG indicated no functional limitation in upper extremity range of motion. The resident’s care plan included a focus that the resident was at risk for burns from hot liquids, with interventions such as encouraging consumption of hot liquids while sitting at a table, requiring use of a cup with a lid for all hot beverages, and specifying that the temperature of hot liquids should not exceed 130°F. Another care plan focus addressed impaired visual function related to legal blindness, with interventions to provide activities adjusted to the resident’s visual disability. During a 10:00 a.m. group activity, Resident #1 spilled hot coffee on her lap. The dietary manager later confirmed that coffee was served at 6:30 a.m., 10:00 a.m., and 2:00 p.m., and that the dietary aide who prepared the coffee for the incident reported the coffee temperature as 140°F, which exceeded the facility’s policy limit of 130°F. Resident #1 reported that she spilled coffee on herself while sitting at a table in the activity room and that the coffee was hot and burned when it was spilled. Subsequent nursing and NP assessments documented two in-house–acquired wounds on the resident’s left upper thigh: one described as a blister and one as a burn, later characterized by the NP as a full-thickness (3rd degree) burn and a partial-thickness (2nd degree) burn. These findings, combined with the lack of documented 10:00 a.m. temperature monitoring and the reported serving temperature of 140°F, demonstrate that the facility did not follow its hot beverage policy and failed to protect the resident from an avoidable burn hazard.
Failure to Maintain Safe Enabler Bar Results in Severe Leg Laceration
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s enabler bar was free from accident hazards, resulting in an actual injury. The facility’s own Bed and Side Rails policy required a designee to inspect all bed frames, mattresses, and bed rails, including grab bars and assist bars, as part of a regular maintenance program. The Maintenance Supervisor job description also required daily tours of the property to identify and correct hazardous conditions and liability hazards. Despite these requirements, the enabler bar on one resident’s bed had a missing end cap, creating a sharp edge that was not identified or corrected prior to use. The affected resident had been admitted with multiple diagnoses, including Peripheral Vascular Disease, Malnutrition, Chronic Kidney Disease, Depression, and Alzheimer’s Disease, and had a BIMS score of 5, indicating severe cognitive impairment. The resident was receiving hospice services and required extensive assistance of one staff person with transfers, as documented in the care plan. On the date of the incident, a CNA assisted the resident with a transfer from a wheelchair to the bed. During this transfer, the resident’s left lower leg rubbed against the enabler bar that had the missing end cap and sharp edge. Nursing documentation recorded that the CNA called an LPN to the room and the LPN observed a large laceration on the resident’s left lower leg with bleeding, which the CNA reported had occurred during the transfer. The LPN noted that the enabler bar had a missing end cap, resulting in a sharp edge, and that the resident’s leg had contacted this area during the transfer. The resident was sent to the emergency department, where records described a very large stellate laceration measuring 25.5 cm on the lateral left lower leg, extending deep to the fascia and requiring extensive cleaning and a complicated repair with internal and external sutures, as well as a tetanus vaccination. Subsequent physician notes documented that the wound required ongoing assessment, daily wound care, and two courses of Bactrim DS due to the extent and depth of the laceration and delayed healing, with sutures removed in stages over several weeks.
Failure to Maintain Required Daily RN Coverage
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was on duty for 8 consecutive hours per day, 7 days a week, as required. Review of the time card report for staff member S5RN from 02/22/2026 through 03/24/2026 showed that on five specific dates—02/25/2026, 02/26/2026, 02/27/2026, 02/28/2026, and 03/01/2026—there were fewer than 8 consecutive hours of RN coverage, with recorded work times of 6.50, 7.48, 6.48, 7.50, and 7.50 hours respectively. During an interview on 03/25/2026 at 9:35 a.m., the Administrator (S1) confirmed that S5RN was the only RN scheduled between 02/22/2026 and 03/21/2026 and acknowledged that the facility did not have 8 consecutive hours of RN coverage on the identified dates. No additional information was provided in the report regarding specific residents, their medical conditions, or any clinical events occurring during the periods without full RN coverage.
Failure to Maintain Adequate Supply of Clean Towels and Bed Linens
Penalty
Summary
The facility failed to provide residents with a safe, functional, sanitary, and comfortable environment by not ensuring the consistent availability of clean bath towels and bed linens. The facility’s own Facility Assessment Tool, updated on 03/23/2026, identified bed and bath linen as non-medical supplies for which PAR levels must be maintained at all times to ensure adequate supplies. Despite this, multiple interviews and record reviews showed that clean linens and towels were often unavailable. One resident, admitted on 12/05/2022 with diagnoses including diffuse traumatic brain injury and allergic rhinitis and a BIMS score of 15 (no cognitive impairment), reported that bath towels and bed linens were often unavailable, most recently during the week of 03/15/2026 through 03/21/2026. Another resident, admitted on 07/12/2023 with diagnoses including type 2 diabetes mellitus and asthma and a BIMS score of 15, had filed a grievance on 01/10/2026 reporting that personal bath towels and sheets were missing from the laundry and later reported that family had to provide personal linens because the facility frequently lacked bath towels and bed linens. Staff interviews corroborated these reports: a laundry staff member stated the facility frequently did not have clean bath towels and bed linens available for residents; a CNA reported that clean bath towels and bed linens were unavailable for residents during the week of 03/08/2026 through 03/14/2026; and the ADON confirmed that the facility did not have clean bath towels and bed linens available for residents on 03/23/2026. This pattern of unavailability affected the facility’s census of 58 residents.
Failure to Report Resident Elopement to State Survey Agency
Penalty
Summary
The deficiency involves the facility’s failure to report a resident elopement to the State Survey Agency as required by state law and by the facility’s own Wandering and Elopement Policy dated 11/15/2023. That policy directs that when a resident returns after an elopement, the DON or charge nurse must examine the resident, notify the attending physician, complete an incident/accident report, document the event in the medical record, and notify regulatory agencies per state guidelines. Record review showed that one resident, admitted on 01/09/2026, had multiple diagnoses including type 2 diabetes mellitus, cognitive communication deficit, aphasia, muscle wasting and atrophy, gait and mobility abnormalities, disorientation, unspecified dementia with anxiety, psychotic and mood disturbance, anxiety disorder, and essential hypertension. A Quarterly MDS documented a BIMS score of 4, indicating severely impaired cognition, and the resident was assessed as an elopement risk level 3 due to a history of attempted elopement at home, wandering with purpose in the facility, and exit-seeking behavior. Progress notes and interviews confirmed that on 02/08/2026 the resident was found outside the facility alone in the flower bed at the front of the building, bent over with hands in the dirt, by an oncoming nurse arriving for her shift. The LPN reported she parked her car, went to assist the resident, and alerted staff inside that the resident was outside alone. The resident’s responsible party similarly reported that the resident had been found outside alone in front of the facility on that date. During interview, the Administrator confirmed that the resident, who had dementia and a BIMS score of 4, had been found outside in the flower bed in front of the facility and acknowledged that this incident was not reported to the State Survey Agency, constituting a failure to report the elopement in accordance with state law and facility policy.
Failure to Revise Care Plan After Elopement and Development of Diabetic Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to revise a resident’s comprehensive care plan following significant changes in condition, specifically an elopement and the development of a diabetic ulcer. The resident was admitted with multiple diagnoses, including type 2 diabetes mellitus, cognitive communication deficit, aphasia, muscle wasting and atrophy at multiple sites, gait and mobility abnormalities, disorientation, unspecified dementia with associated anxiety, psychotic and mood disturbances, an anxiety disorder, and essential hypertension. Progress notes documented that the resident was found outside the facility in a flower bed, bent over with hands in the dirt, after having eloped from the building. Further review of the resident’s progress notes showed that a diabetic ulcer was identified on the resident’s right heel the day after the elopement. Despite these documented changes in condition, review of the resident’s comprehensive care plan revealed no revisions to address the actual elopement event or the new diabetic ulcer on the right heel. During an interview, the MDS Coordinator confirmed that the resident’s care plan should have been revised to reflect both the elopement and the development of the diabetic ulcer, but it was not.
Failure to Implement and Document Diabetic Foot and Heel Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards of practice and the comprehensive care plan for a resident with diabetes and multiple comorbidities. The resident was admitted with type 2 diabetes mellitus, cognitive communication deficit, aphasia, muscle wasting and atrophy, gait and mobility abnormalities, disorientation, unspecified dementia with associated psychiatric symptoms, anxiety disorder, and hypertension. On admission, the Minimum Data Set and skin assessment documented a deep tissue injury on the right heel. A nurse practitioner’s progress note dated shortly after admission described a deep tissue injury on the right heel being treated with gentian violet and foam and noted the heel was tender to touch. However, there were no corresponding physician’s orders for wound care treatment on the January and early February physician order sheets, and the treatment administration records for that same period showed no wound care treatments provided. The resident’s care plan for diabetes included an approach to check the body for breaks in the skin and treat promptly as ordered by the physician, but the facility did not develop and implement specific approaches addressing the documented right heel injury. A wound care nurse’s progress note later identified a diabetic ulcer on the right heel, described as tender and spongy, and documented application of gentian violet–soaked gauze and foam dressing. Only then was a physician’s order written to monitor the right heel and apply gentian violet dampened gauze and a protective dressing on specified days, with the treatment administration record showing documentation of these treatments on only three dates. The resident’s responsible party reported that the resident was discharged and subsequently required emergency department treatment for cellulitis due to a diabetic ulcer on the right heel, for which antibiotics were prescribed. The wound care nurse confirmed the initial documentation of a deep tissue injury without any physician’s orders for treatment and that the diabetic ulcer was not identified until nearly a month after admission, and the nurse practitioner confirmed he examined the right heel only once during that period.
Failure to Follow Hand Hygiene and Glove Protocols During Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to maintain an infection prevention and control program during incontinence care, specifically related to hand hygiene, glove use, and handling of soiled linens. The facility’s own policy for bladder incontinence care requires staff to perform handwashing or use alcohol gel, don disposable gloves, cleanse the perineal and anal areas, then remove and discard gloves and perform hand hygiene before proceeding. During observed incontinence care for one resident, a CNA donned clean gloves and used perineal wipes to remove bowel movement from the resident’s buttocks, then, without changing gloves or performing hand hygiene, placed a clean incontinence pad and brief under the resident. The CNA placed a soiled brief and urine-soaked bed pad at the foot of the bed on top of the resident’s clean comforter, then disposed of the soiled brief in the trash, spread a clean incontinence pad on the bed, and secured a clean brief, all without changing gloves or performing hand hygiene. The same CNA continued to touch the resident’s clean clothing, body, wheelchair armrests, and room door, transferred the resident to the wheelchair, and moved the resident into the hallway, then returned to retrieve the soiled incontinence pad and carried it down the hall to the soiled linen barrel before finally disposing of gloves, again without any observed hand hygiene during the entire episode of care. In a separate observation involving another resident, two CNAs provided incontinence care without performing hand hygiene before donning gloves. One CNA removed bowel movement from the resident’s buttocks, discarded the soiled brief, removed soiled gloves, and donned clean gloves without hand hygiene, then touched the resident’s extremities, bed linens, and applied a clean brief and incontinence pad. The CNA again changed gloves and dressed the resident in a clean gown, touching multiple body areas, without hand hygiene. The second CNA unfastened the brief, confirmed the resident remained soiled, wiped remaining stool, and helped secure the clean brief without changing soiled gloves or performing hand hygiene. Both CNAs later confirmed in interviews that they should have performed hand hygiene and changed gloves appropriately, and the DON confirmed staff are expected to change gloves when soiled or moving from contaminated to clean areas, sanitize hands between glove changes and between residents, and avoid placing soiled linen on clean linen.
Failure to Honor Resident Dignity and Discontinue Unnecessary Isolation Practices
Penalty
Summary
The deficiency involves failure to honor residents' rights to dignity and self-determination. One resident, who was lying in bed and requested a bedpan, was observed on 03/25/2026 at 8:59 a.m. using the call light with surveyor assistance. When the CNA entered the room, she stated the resident was wearing a diaper, could not get up due to left-sided weakness from a stroke, and said the resident "can go in her diaper" instead of providing a bedpan as requested. A COTA later reported that therapy had recommended the resident use a bedpan and had removed the bedside commode the previous day, and that the resident did not want to use a diaper. The COTA also stated the resident’s left arm was flaccid and that she required maximum assistance of two people. A second deficiency involved another resident who continued to receive meals on disposable dishware in the dining room after contact isolation precautions had been discontinued. This resident had diagnoses including vascular dementia, enterocolitis due to Clostridium difficile, hyperlipidemia, heart failure, and depression, and had a BIMS score of 9, indicating moderately impaired cognition. A physician order for single room isolation with contact precautions had been discontinued on 02/17/2026, yet on 03/23/2026 at 11:20 a.m., the resident was observed receiving a lunch tray on disposable dishware while seated in the dining room. The ADON confirmed the resident was no longer on contact precautions and should not have been receiving meals on disposable dishware.
Failure to Keep Call Light Within Reach for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s call light was accessible as required by facility policy and necessary to reasonably accommodate the resident’s needs. The facility’s policy on answering call lights, dated 01/16/2026, states that when a resident is in bed or confined to a chair, the call light must be within easy reach. Resident #3 was admitted on 12/07/2023 with diagnoses including mononeural disorder, paraplegia, epilepsy, and peripheral vascular disease. A quarterly MDS with an ARD of 03/03/2026 documented a BIMS score of 6, indicating severe cognitive impairment, and showed the resident required setup assistance with eating, was dependent for toileting and personal hygiene, and needed substantial/maximal assistance to roll left to right. On multiple observations on 03/24/2026, surveyors found the resident’s call bell out of reach despite the resident’s reliance on it to express needs. At 10:12 a.m., the resident was lying in bed with eyes closed and the call bell was on the floor on the right side of the bed, not within reach. At 12:24 p.m., the resident was awake and alert in bed, and again the call bell was on the floor and not reachable; the resident stated he could not reach it. During an interview at 12:45 p.m., a CNA familiar with the resident confirmed the resident could express needs with short responses and used the call bell. At 12:48 p.m., with the CNA present, the call bell was still on the floor and not within reach, and the CNA acknowledged it should have been accessible. Later observations at 1:41 p.m. and 3:00 p.m. found the resident awake and alert in a reclined position in a Geri chair, with the call bell hanging on the side of the bed and again out of reach; the DON, present at 3:00 p.m., confirmed the call bell was not within reach and should have been.
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